Newborn Care

Overview of the Newborn Period

  • Definition of Newborn Period:

    • Time from birth through the 28th day of life.

    • During this time, the newborn adjusts from intrauterine to extrauterine life.

  • Importance of Transitioning:

    • Transition from fetus to newborn represents the most complex physiologic adaptation in human experience, involving virtually every organ system.

Normal Vital Signs in the Newborn

  • Respirations: 30–60 breaths per minute

  • Apical Pulse: 120–160 beats per minute (bpm), varies:

    • 100 bpm while sleeping

    • 180 bpm while crying

  • Blood Pressure:

    • Systolic: 65–95 mm Hg

    • Diastolic: 30–60 mm Hg

  • Temperature:

    • Axillary: 36.5–37.3° C (97.7–99.5° F)

Neonatal Systems Overview

Respiratory

  • Development of the Lungs:

    • Alveoli produce fetal lung fluid during fetal life, aiding lung development.

    • Surfactant lines the alveoli, reducing surface tension to keep them open.

    • Fetal lung fluid moves into interstitial spaces before, during, and after birth.

Cardiovascular

  • Key Changes:

    • Increases in blood oxygen levels and shifts in pressure in the heart and lungs.

    • Closing of umbilical vessels, ductus arteriosus, foramen ovale, and ductus venosus during birth.

  • Potential Outcomes:

    • Asphyxia pulmonary hypertension may cause foramen ovale to open

    • Murmur

Thermoregulation

  • Preventing Heat Loss:

    • Keep the infant dry and covered.

    • Avoid contact with cold surfaces and drafts.

  • Thermogenesis

    • Indicators of Thermogenesis:

      • Restlessness and crying.

      • Increased activity and flexion.

      • Rises in metabolism and vasoconstriction.

      • Nonshivering Thermogenesis:

        • Involves the utilization of brown fat.

    • Consequences of Thermogenesis:

      • Increased oxygen and glucose consumption, potentially resulting in respiratory distress, hypoglycemia, and jaundice.

Hepatic

  • Key Functions of the Liver:

    • Maintenance of blood glucose levels.

    • Conjugation of bilirubin.

    • Production of blood coagulation factors.

    • Iron storage.

    • Drug metabolism.

  • Coagulation Factors:

    • Critical factors II, VII, IX, and X depend on vitamin K; newborns have low levels.

    • Prophylactic vitamin K is administered at birth due to transient blood coagulation alterations.

    • Coagulation does not reach adult levels until about 9 months.

  • Bilirubin Conjugation:

    • Conjugation Process:

      • Converts lipid-soluble bilirubin to water-soluble form.

      • Unconjugated bilirubin is a potential toxin.

      • In utero, fetal bilirubin crosses placenta to be conjugated and excreted by mother

    • Implications for Newborns:

      • Increased bilirubin levels post-birth can lead to jaundice.

      • Complications in conjugation can arise from:

        • High beta-D-glucuronidase levels.

        • Exclusively breastfed infants.

        • Delayed bacterial colonization of the gut.

        • Hyperbilirubinemia

Gastrointestinal System

  • Transition from thick, greenish-black meconium to transitional stools, and finally to milk stools.

    • Meconium

      • Term newborn: pass within 8-24 hours of life

      • Formed in utero

      • Thick, tarry-black or dark-green

    • Transitional

      • 24-48 hours of life

      • Part meconium, part fecal matter

      • Thin brown or green

    • Frequency and character of stools vary based on breast or formula feeding.

      • Breastfed: frequent, seedy, mustard colored

      • 2-3 per day to 10 daily

      • Should be soft (not difficult to pass or hard indicated constipation)

Urinary System

  • Less effective at filtering, reabsorbing, and maintaining fluid and electrolyte balance than adult kidneys.

  • Expected first void within 24 hours.

  • Normal diuresis can cause a weight loss of 5–10%.

  • Newborn is 75% water.

Immune System Functions

  • Lower effectiveness in fighting infections compared to older children and adults.

  • Immunoglobulins:

    • IgG: Crosses the placenta, providing passive temporary immunity.

    • IgM: Protects against gram-negative bacteria.

    • IgA: Must be produced by the infant as it does not cross the placenta.

Neurologic and Sensory-Perceptual Function

  • Reactivity States:

    • Sleep states

      • Deep sleep: still, quiet, regular respirations

      • Active or light sleep: REM, twitchy, irregular respirations

    • Alert states

      • Drowsy: transitional, hazy, glazed half-open eyes

      • Quiet alert: best for interaction and feeding; calm, focused, eyes wide-open

      • Active alert: awake, moving, maybe fussy or showing early hunger signs

      • Crying: due to overstimulation, urgent need, hunger, discomfort

  • Behavioral Capacities:

    • Self-quieting Ability: Impaired in neurologically compromised newborns, necessitating greater caregiver support.

    • Habituation: Ability to respond to complex stimulations.

Sensory Capacities of the Newborn

  • Visual Capacity:

    • Preference for human faces and high-contrast patterns; nearsightedness.

  • Auditory Capacity:

    • Responds well to sounds, suggesting organized behavioral reactions.

    • Lack of auditory development can increase the risk for Sudden Infant Death Syndrome (SIDS).

Care of the Newborn

Initial Assessment and Care

  • Apgar Scoring:

    • Evaluate heart rate, respiratory effort, muscle tone, reflex irritability, skin color, scoring of 0, 1, or 2 for each component.

    • A score of 7-10 indicates good condition. Less than 7 requires repeat scoring every 5 minutes up to 20 min. Less than 3 correlates with neonatal mortality.

    • APGAR Score Components: (Scores of 0, 1, or 2)

      • Heart Rate:

        • 0: Absent

        • 1: Below 100

        • 2: Over 100

      • Respiratory Effort:

        • 0: Absent

        • 1: Slow, irregular

        • 2: Good, crying

      • Muscle Tone:

        • 0: Limp

        • 1: Some flexion

        • 2: Active motion

      • Reflex (Response to catheter in nostrils):

        • 0: No response

        • 1: Grimace

        • 2: Cough or sneeze

      • Color:

        • 0: Blue, pale

        • 1: Body pink, extremities blue

        • 2: Completely pink

    • Interpretation of Scores:

      • 7 to 10: Normal

      • 4 to 6: Moderately depressed

      • 0 to 3: Needs immediate resuscitation

  • Clamping the Cord:

    • Clamps placed 1.3–2.5 cm (0.5–1 in.) from abdomen, avoiding clamping the abdominal skin.

    • Benefits of delayed clamping include increased blood volume and reduced risk of anemia.

  • Banking Cord Blood:

    • Parents can store cord blood for potential use in treating disorders.

  • Newborn Identification and Security:

    • Uniform ID bands for newborns and parents to prevent abduction.

  • Wrapping a Baby in a Blanket

    1. Wrap the right side of the blanket over the baby's body.

    2. Tuck the bottom of the blanket up over the baby's feet.

    3. Wrap the left side of the blanket over the baby and tuck in.

In-Depth Assessment of Newborn

  • Gestational Age Establishment:

    • Use of Ballard scoring system for postnatal assessment.

    • New Ballard Score incorporates additional criteria.

  • Physical Maturity Characteristics:

    • Assess skin (including birthmarks), head shape, eye condition, nose, mouth, ears, neck, chest, abdomen, genitals, extremities, spine.

  • Neurological status

    • Observation and Reflex Testing:

      • Evaluate general characteristics like alertness, posture, muscle tone, and presence of common reflexes

    • Commonly Observed Reflexes:

      • Tonic neck reflex: turning newborns head to one side causes those extremities to extend and opposite extremities to flex (turn face towards the left, the left extremities extend and right extremities flex)

      • Grasping reflex

      • Babinski reflex: toe extension when plantar surface is stimulated

      • Galant reflex: trunk incurvation

      • Rooting reflex: facing and attempted to root to bottle

      • Moro reflex: startle

Nursing Considerations

Vitamin K and Eye Infection Prophylaxis

  • Vitamin K Deficiency:

    • Prophylactic injection of vitamin K (phytonadione) to prevent bleeding complications.

  • Eye Infection Prevention:

    • Prophylactic treatment for potential gonorrheal infections, commonly using erythromycin.

Circumcision

  • Reasons for Circumcision:

    • Prevention of certain health conditions, religious beliefs, parental preference.

  • Reasons Against Circumcision:

    • Belief that surgery is unnecessary for uncommon conditions.

  • Complications of Circumcision:

    • Includes hemorrhage, infection, and unsatisfactory cosmetic outcomes.

Parent-Newborn Attachment

  • Strengthening Bonds:

    • Involve family members in care and be sensitive to cultural beliefs and values.

    • Quieting activities and skin-to-skin contact encouraged.

General Instructions for Newborn Care

  • Safety Principles:

    • Position the baby on their back for sleep.

    • Demonstrate bathing, cord care, and provide temperature assessment guidelines.

Preparation for Discharge

  • Swaddling Techniques:

    • Helps maintain body temperature and provides security.

  • Car Seat Safety:

    • Newborns must be in a rear-facing car seat until they are at least 2 years old or reach the designated weight/height limits.

  • Immunization and Screening Programs:

    • Important screenings for various conditions should be communicated to parents.

Complications

Neonatal Abstinence Syndrome (NAS)

  • Management: minimize stimuli, enhance feeding abilities

Phenylketonuria (PKU)

  • Genetic disorder affecting amino acid metabolism

  • Management: specialized diet

  • Complications: severe intellectual disability

Sepsis Neonatorum

  • General Signs:

    • Temperature instability (usually low).

    • Nurse’s subjective feeling that the infant is not doing well.

    • Other signs:

      • Tachypnea.

      • Respiratory distress, evident through nasal flaring, retractions, and grunting.

      • Apnea.

Murmur

  • Causes of Murmurs:

    • Turbulent blood flow.

    • Abnormal or stenosed valves, atrial or ventricular septal defects.

    • Increased blood flow across normal valves.

  • Statistics:

    • 90% of murmurs in newborns are transitory and not associated with anomalies.

  • Common Causes:

    • Incomplete closure of ductus arteriosus or foramen ovale.

    • Murmurs may be absent even in severe cardiac anomalies.

Hyperbilirubinemia

  • Timing:

    • Physiologic jaundice: appears after the first 24 hours due to hemolysis and liver immaturity.

    • Nonphysiologic jaundice: may arise from insufficient intake.

    • Breast Milk Jaundice: occurs after 3–5 days and may take up to 3 months to resolve; due to insufficient intake

    • Late-onset jaundice: occurs after 3-5 days of life and may take up to 3 months to resolve

  • Factors Contributing to Hyperbilirubinemia:

    • Increased erythrocyte production and short red blood cell life.

    • Lack of albumin-binding sites and liver immaturity.

    • Blood incompatibility.

    • Preterm and late preterm infants.

    • Lack of intestinal flora, delayed feeding, and potential bruising from birth.

    • Trauma resulting bruising or cephalhematoma.

    • Fatty acids from cold stress or asphyxia.

    • Family background

    • Diabetic mother

    • Certain drugs/medications

    • Hypoglycemia

    • Infection

    • Delayed feedings

    • Lack of intestinal flora

  • Management

    • Phototherapy:

      • Most common treatment involving fluorescent lights.

    • Exchange Transfusions:

      • Conducted when phototherapy does not adequately reduce dangerous bilirubin levels.

      • This procedure removes sensitized red blood cells, maternal antibodies, and unconjugated bilirubin.

Hemorrhagic Disease of the Newborn

  • Bleeding disorder in newborns

  • Pathophysiology: immature GI tract interferes with absorption of vitamin K > interferes with synthesis of coagulation factors > newborn bleeds

  • Manifestations:

    • Blood in stool

    • Blood in urine

    • Oozing around umbilical cord

  • Risk factors:

    • No prophylactic vitamin K

    • Exclusively breastfed

    • Maternal seizure disorder treated with anticonvulsants